A bill introduced in the U.S. House of Representatives in late March seeks to increase transparency around prior authorization decisions.
The Reducing Medically Unnecessary Delays in Care Act of 2025 (H.R. 2433) would require Medicare coverage decisions, including prior authorization requirements and adverse coverage decisions, to be based on written clinical criteria developed in consultation with physicians. The bill mandates that all preauthorization decisions and adverse determinations must be made by a practicing physician in the same specialty as the health care provider who typically manages the medical condition or disease or provides the health care service. Stakeholder organizations, including the American Medical Association, are advocating in favor of the bill’s passage, which was referred to the House Energy & Commerce and Ways & Means committees for further consideration.
The bill outlines the following contract requirements for prior authorization medical decisions for Medicare administrative contractors (MACs) and Medicare Advantage (MA) plans:
- All prior authorization decisions must be based on the medical necessity or appropriateness of such service and on written clinical criteria.
- If no independently developed evidence-based standards exist for a particular health care service, coverage of the health care service may not be denied based solely on the grounds that the health care service does not meet an evidence-based standard.
- Prior authorization decisions must be based on input from actively practicing physicians within the service area where the written clinical criteria are to be employed.
- MACs and MA plans shall apply written clinical criteria for the purpose of preauthorization review consistently.
- Any current preauthorization requirements and restrictions should be readily accessible online to subscribers, health care providers, and the general public.
- Written notice of a new or amended requirement or amendment must be publicly available no less than 60 days before the requirement or restriction is implemented and must be updated on the MAC or MA plan website.
- The MAC or MA plan must make statistics available regarding preauthorization approvals and denials for coverage or payment of health care services under the Medicare program.
Sources:
https://www.congress.gov/bill/119th-congress/house-bill/2433/text
